Fall Prevention Medication Review

Directions: This form is intended to be used as a checklist by the Pharmacist to identify medications which may further adversely influence a patient’s risk for fall.

The patient IS taking the following medications, which may INCREASE the risk of falling:

PSYCHOTROPICS

Sedative-hypnotics, including ambien, zopiclone, and especially benzodiazepines (BZDs)

Neuroleptics (antipsychotics)

Tricyclic antidepressants (TCAs)

Selective serotonin reuptake inhibitors (SSRIs)

CARDIOVASCULAR MEDICATIONS

Digoxin

Antihypertensives, especially diuretics: diuretic ACE I ARB CCB β-blocker

Class 1A antiarrhythmics (procainamide, quinidine, and disopyramide)

OTHER MEDICATIONS

Anticholinergics – including antihistamines, TCAs, and antipsychotics

Anticonvulsants

Opioid Analgesics (within first 48 hrs of initiation or dosage increase)

OTHER RISK FACTORS TO CONSIDER

Elderly patients (65 years of age or older)

Impaired renal function

Four or more scheduled medications

Anticoagulants/Antiplatelets (may increase the risk of injury from a fall)

Untreated: osteoporosis  urinary incontinence delirium  pain (may have an increased risk of injury from falls)

PLEASE CONSIDER THE FOLLOWING RECOMMENDATIONS TO REDUCE THE RISK OF FALLING:

Pharmacist: ______Date: ______

Source: Adapted from Fall Medication Regimen Review form created by:

Polly Robinson, PharmD, CGP, FASCP St. John Medical Center, Tulsa, OK

PSYCHOTROPICS

- Sedative-hypnotics, including zopiclone, and especially benzodiazepines (BZDs)

  • BZDs impair balance centrally and peripherally. BZDs may also cause CNS depression leading to impaired reaction times. Risk is greater at higher doses for both long- and short-half-life BZDs.
  • There is no clear benefit of short-acting BZDs or newer agents in reducing falls.
  • Risk of fall is greatest in the first 15 days of therapy or when increasing doses of BZDs.
  • Risk is increased with patients taking more than one BZD; therefore, combinations should be avoided.

Zopiclone - The recommended dosage in elderly is 3.75 mg, possibly increased to 7.5 mg. Zopiclone causes increased body sway, which is a surrogate marker for fall risk. - Neuroleptics (Atypical and Typical Antipsychotics)

  • May cause EPS, sedation, gait abnormalities, dizziness, blurred vision, cognitive impairment, and orthostatic hypotension.
  • Newer antipsychotics may have improved side-effect profiles, although there is no evidence relating to falls.

- Tricyclic antidepressants (TCAs)

  • Doses ≥ 50mg of amitriptyline are associated with an increased risk for falls.
  • Proposed mechanism of action includes orthostatic hypotension, sedation, and/or cognitive impairment due to anticholinergic effects.

- Selective serotonin reuptake inhibitors (SSRIs)

  • New use of SSRIs is associated with a greater risk for falls. Recommend starting with a low dose for the 1st week, then slowly increasing to therapeutic levels.
  • Doses ≥ 20mg of fluoxetine have a higher risk for falls.
  • May induce hyponatremia, which can lead to delirium; recommend monitoring electrolytes.

CARDIOVASCULAR MEDICATIONS

- Digoxin

  • There is a weak association between digoxin and falls. Digoxin is renally-eliminated.

- Antihypertensives

  • Antihypertensives have been proposed to contribute to fall risk via postural hypotension (drop in SBP of ≥ 20 mmHg, in DBP of ≥ 10 mmHg, OR to a pressure of < 90 mmHg when standing).
  • Diuretics have been significantly associated with falls (vertigo, orthostatic hypotension, frequent urination). Most studies have found a non-significant relationship between other antihypertensives and falls.
  • Inadequate treatment of a cardiovascular disease may also be a factor in increasing fall risk.

- Class 1A antiarrhythmics (procainamide, quinidine, and disopyramide)

  • The relationship between these agents and falls may be due to the adverse effects of the medication or the disease (low blood pressure with light-headedness).

OTHER MEDICATIONS

- Anticholinergics

  • Anticholinergic properties include dizziness, sedation and blurred vision. Anticholinergics include atropine, benztropine, hyoscine, scopolamine, etc.
  • Sedating antihistamines have strong anticholinergic properties and the half-life may be extended in elderly patients. For example, the half-life of diphenhydramine is about 13.5 hrs in elderly patients and about 2 to 10 hrs in younger adults.
  • Other drugs with anticholinergic properties include TCAs, neuroleptics, antispasmodics (oxybutynin), and some antiemetics (prochlorperazine, metoclopramide, promethazine, trimethobenzamide, etc.).

- Anticonvulsants

  • May cause dizziness, ataxia, orthostatic hypotension, blurred vision, somnolence, and confusion, which are greatest at the beginning of therapy or after increases in dose.

Opioid Analgesics

  • Opioids, in general, do not cause falls. However, they may cause sedation, dizziness, or confusion in the first 48 hours after initiation or a dose increase.
  • Patients usually develop tolerance to these side effects within 2 to 3 days of a stable dose. Therefore frequent dosage changes or use of PRNs may increase the risk of side effects.
  • Pain may increase the risk of falls. Therefore, adequate pain control is important.

Source: Adapted from Fall Medication Regimen Review form created by:

Polly Robinson, PharmD, CGP, FASCP St. John Medical Center, Tulsa, OK